Case Report
Copyright ©The Author(s) 2021. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Clin Cases. May 26, 2021; 9(15): 3787-3795
Published online May 26, 2021. doi: 10.12998/wjcc.v9.i15.3787
Bilateral cerebral infarction in diabetic ketoacidosis and bilateral internal carotid artery occlusion: A case report and review of literature
Yi-Chung Chen, Su-Ju Tsai
Yi-Chung Chen, Su-Ju Tsai, Department of Physical Medicine and Rehabilitation, Chung Shan Medical University Hospital, Taichung 40201, Taiwan
Author contributions: Chen YC is the first author and wrote the case report and completed the literature review; Tsai SJ performed the final editing and prepared the paper for approval by the authors; all authors read and approved the final manuscript.
Informed consent statement: Informed written consent was obtained from legal representative.
Conflict-of-interest statement: The authors declare that they have no conflict of interest.
CARE Checklist (2016) statement: The authors have read the CARE Checklist (2016), and the manuscript was prepared and revised according to the CARE Checklist (2016).
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Corresponding author: Su-Ju Tsai, MD, MS, Associate Professor, Director, Department of Physical Medicine and Rehabilitation, Chung Shan Medical University; Director, Department of Physical Medicine and Rehabilitation, Chung Shan Medical University Hospital, No. 110 Sec.1, Jianguo N. Rd., Taichung 40201, Taiwan. sujutsai@gmail.com
Received: January 30, 2021
Peer-review started: January 30, 2021
First decision: February 25, 2021
Revised: March 2, 2021
Accepted: March 29, 2021
Article in press: March 29, 2021
Published online: May 26, 2021
Abstract
BACKGROUND

Diabetic ketoacidosis (DKA) is a serious complication of type 1 diabetes mellitus (T1DM). Very rarely does DKA lead to cerebral edema, and it is even rarer for it to result in cerebral infarction. Bilateral internal carotid artery occlusion (BICAO) is also rare and can cause fatal stroke. Moreover, case reports about acute cerebral infarction throughout both internal carotid arteries with simultaneous BICAO are very scarce. In this study, we present a patient with BICAO, T1DM, hypertension, and hyperlipidemia, who had a catastrophic bilateral cerebral infarction after a DKA episode. We briefly introduce BICAO and the mechanisms by which DKA results in cerebral infarction.

CASE SUMMARY

A 41-year-old woman presented with ischemic stroke that took place 3 mo prior over the left corona radiata, bilateral frontal lobe, and parietal lobe with right hemiplegia and Broca’s aphasia. She had a history of hypertension for 5 years, hyperlipidemia for 4 years, hyperthyroidism for 3 years, and T1DM for 31 years. The first brain magnetic resonance imaging not only revealed the aforementioned ischemic lesions but also bilateral internal carotid artery occlusion. She was admitted to our ward for rehabilitation due to prior stroke sequalae. DKA took place on hospital day 2. On hospital day 6, she had a new massive infarction over the bilateral anterior cerebral artery and middle cerebral artery territory. After weeks of aggressive treatment, she remained in a coma and on mechanical ventilation due to respiratory failure. After discussion with her family, compassionate extubation was performed on hospital day 29 and she died.

CONCLUSION

DKA can lead to cerebral infarction due to several mechanisms. In people with existing BICAO and several stroke risk factors such as hypertension, T1DM, hyperlipidemia, DKA has the potential to cause more serious ischemic strokes.

Keywords: Type 1 diabetes mellitus, Diabetic ketoacidosis, Bilateral internal carotid artery occlusion, Cerebral infarction, Case report

Core Tip: Diabetic ketoacidosis (DKA) causes vascular endothelial injury, systemic inflammation, vasoconstriction, abnormal coagulation cascade, increased platelet aggregation, and increased blood viscosity, all of which are associated with cerebral infarction. Bilateral internal carotid artery occlusion (BICAO) is a rare condition that can give rise to devastating ischemic strokes. DKA acts as an additional risk factor for ischemic stroke in a high-risk patient with BICAO, hypertension, hyperlipidemia, and type 1 diabetes mellitus.